Individual at Leeds

Investigation into the circumstances surrounding the
death of a man in September 2008
at HMP Leeds
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2009
Final Report: Date: March 2009
This is a report into the circumstances surrounding the death of a man at HMP
Leeds in September 2008.
Shortly after lunch, the alarm was raised by his cellmate following the man collapsing
in their shared cell. The officer who attended asked for healthcare assistance. Staff
and paramedics attempted cardio pulmonary resuscitation, and he was taken to
hospital. It was there that he was pronounced dead at 1.40pm. He had suffered a
pulmonary embolism, or blood clot, in his heart. He was 48 years old. I offer my
sincere sympathy and condolences to his family and friends for their loss.
On first reception into Leeds in 2006, the man had reported no medical concerns
apart from stress caused by the charges he was facing. His stress levels quickly
reduced once he was placed in a wing with other vulnerable prisoners. There is no
further record of him ever complaining about any health concerns. His sudden
collapse was a shock to all concerned.
The investigation was carried out on my behalf by my colleague. A clinical review of
the man’s healthcare at HMP Leeds was undertaken by a representative from the
local Primary Care Trust. I am grateful for his comprehensive account. I would also
like to thank the Governor of Leeds and his staff for their co-operation and
assistance with this investigation. Particular thanks go to the Litigation Manager at
HMP Leeds, for his help throughout the investigation process as Liaison Officer.
I am satisfied that staff did all they could to try to save the life of the man. However, I
make four recommendations from this investigation and the associated clinical
review.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2009
Final Report: Date: March 2009 2
CONTENTS
Summary
The Investigation Process
HMP Leeds
Key Findings
Issues
Recommendations
Final Report: Date: March 2009 3
SUMMARY
The man had been remanded into custody at HMP Leeds on 29 April 2006 and,
following conviction, was sentenced to 16 years and six months imprisonment. He
had been in prison previously on a number of occasions.
On arriving at Leeds, the man was initially concerned about his safety which caused
him some stress. However, this was reduced after he asked to be placed on Rule
45. (This is a rule whereby prisoners who feel vulnerable, either because of the
nature of their offence or for other reasons, can be separated from the rest of the
prison population.) He fitted into the regime on A Wing (the vulnerable prisoner unit)
and followed the rules.
He did not report any further concerns about his physical health. He collapsed at
approximately 12.27pm in his cell on 16 September 2008. The alarm was raised by
his cellmate and the officer who responded called for healthcare assistance. Cardio
pulmonary resuscitation (CPR) was carried out swiftly until the paramedics arrived
and they continued trying to resuscitate the man. However, he was declared dead
on his arrival at Leeds General Infirmary at 1.40pm.
Final Report: Date: March 2009 4
THE INVESTIGATION PROCESS
1. The man died on 16 September 2008. The Ombudsman’s terms of reference
and notices of investigation were sent to the prison within three days of his
death. The notices were displayed for prisoners and staff. No one came
forward in response.
2. My investigator contacted the prison and asked for the man’s prison records.
The records from Leeds and previous prisons were examined, and my
investigator drew up a list of people to interview. He attempted to contact the
man’s cellmate but, as he had been released, this proved unsuccessful.
3. A doctor was contracted by the local Primary Care Trust (PCT) to undertake a
clinical review of the healthcare received by the man while in custody. The
review is included as an annexe to this report.
4. My investigator travelled to Leeds for two days in early November 2008 to
interview wing and healthcare staff.
5. Members of my staff offered to meet the man’s family following his funeral but
they chose not to do so and did not raise any issues that they wished my
investigator to look into. A copy of this report will be sent to the man’s family.
Final Report: Date: March 2009 5
HMP LEEDS
8. HMP Leeds is a category B local prison dating from 1847 serving the courts in
West Yorkshire. It accepts all adult male prisoners and had an operating
capacity of 1,004 (at the time of the man’s death) across six wings.
9. Leeds was last inspected by HM Chief Inspector of Prisons in December
2007. The inspection found that, although Leeds was not performing
sufficiently well in any of the Chief Inspector’s key areas, there had been
progress in all aspects of the prison as managers sought to introduce
improvements.
10. The Chief Inspector said A Wing contained vulnerable prisoners who had no
restrictions on their regime. She said that, although the wing was shared
between sex offenders and others (such as those in debt), most prisoners felt
relatively safe on A Wing.
11. The healthcare centre currently provides beds for 15 patients. Although half
the prisoners surveyed by HM Chief Inspector said that the healthcare
services were either good or very good, her report made a number of
recommendations. HM Chief Inspector of Prisons also commented that not all
staff had had resuscitation training in the last 12 months, and recommended
that this should be rectified.
12. Each prison has its own Independent Monitoring Board made up of volunteers
from the community. The Board’s role is to ensure that the prison is properly
run and that prisoners are treated decently. Each Board produces an annual
report for the Secretary of State. In their 2008 annual report on Leeds the
IMB expressed its concern over the number of life-sentenced and IPP
(indeterminate sentence for public protection) prisoners who found it difficult
to take part in the courses and programmes necessary for consideration for
release. The IMB also had concerns over the reception and visits areas, but
praised the staff’s efforts regarding diversity and safer custody.
13. Leeds suffered four deaths in custody in 2008, of which three were due to
natural causes (including that of the man). There do not appear to be any
significant similarities between them.
Final Report: Date: March 2009 6
KEY FINDINGS
Between 29 April 2006 and 3 December 2007
14. The man arrived at HMP Leeds on 29 April 2006 on remand for serious
offences. He underwent his first reception health screen when he revealed
that he was not receiving any current medication, that his family had no
history of any illnesses, and that he had no concerns about his physical
health. He did not report any previous heart problems. He was five feet nine
inches tall, weighing 12 stone with blood pressure of 116/76 and a pulse of 73
(both within normal range).
15. A cell sharing risk assessment (CSRA) was carried out the same day and he
was judged to be high risk because he said he would attack his cellmate if he
felt threatened. He applied under Rule 45 for Vulnerable Prisoner (VP) status
on the same day due to the nature of his offence. The CSRA notes that his
risk assessment could be lowered to medium once his application for VP
status was approved. He was located in cell A4-28 on A Wing (the vulnerable
prisoner unit).
16. The man initially suffered from stress due to the nature of the charges he was
facing. He had been abused by other prisoners. However, following two
appointments to discuss his stress with doctors in late 2006, there is no
record of any further medical ailments.
17. In late 2006, he was sent to HMP Hull to await his trial in February 2007. He
remained concerned about his safety and again asked to be placed on Rule
45. He was initially on segregated on K Wing as he refused to leave his cell
until he was placed on Rule 45.
Between 3 December 2007 and 16 September 2008
18. The man returned to Leeds on 3 December 2007 having refused to go to
HMP Dovegate where there was no VP scheme. His application for VP status
was approved and he returned to A Wing. Two officers were assigned as his
personal officers. His behaviour was described as good and he kept his cell
clean and tidy. He was polite and conversational with his personal officers,
but did not come to them with any concerns or issues. One of his personal
officers described him as wanting to better himself while in prison and being
no trouble at all. She remarked that, while some prisoners could be quite
demanding, he never complained or asked for things from the wing staff.
19. Officers said that the man mixed with the other prisoners well but kept himself
to himself much of the time. He preferred to be busy and worked hard in the
workshops, achieving a National Vocational Qualification (NVQ) in the sewing
workshop in January 2008. He also built matchstick models for a charity to
sell. This occupied much of his time and the Governor authorised the
reimbursement of his costs as the models were for charity. He was also in the
early stages of applying to be both a Listener and a Toe-to-Toe mentor. A
Listener is a prisoner trained by the Samaritans to listen to other prisoners
Final Report: Date: March 2009 7
who want to talk to someone. A Toe-to-Toe mentor assists other prisoners
with literacy. Due to his consistent good behaviour, cleanliness and hard
work his personal officers were in the process of recommending the man for
‘enhanced status’. (Enhanced status is part of the prison’s Incentives and
Earned Privileges scheme and grants prisoners the right to wear their own
clothes, and allows them an extra visit and extra time out of their cells.)
16 September
20. On 16 September 2008, the man collected his lunch as usual and took it back
to his cell (A3-11) on the second landing. His cellmate later told staff that the
man complained of feeling unwell after eating his lunch. He got down from his
bunk and went into the toilet area where he vomited, and then collapsed. The
cellmate pressed his emergency cell bell and an officer responded to the
alarm at approximately 12.27pm. When he reached the cell he spoke to the
cellmate through the door. The cellmate told the officer that the man had
collapsed.
21. The officer first on scene immediately radioed Hotel 3 for medical assistance
and then opened the cell door. (Hotel 3 is the radio call sign for a particular
radio that one healthcare staff member will always be holding. This member
of staff acts as first responder to any medical situation.) Once inside the cell
the officer saw the man lying in the recessed toilet area. The cellmate had
already placed him in the recovery position, and the officer could see that the
man had vomited. The officer approached the man and realised he had
difficulty breathing. He immediately radioed a code blue alarm. (A code blue
alarm requests immediate healthcare assistance and indicates a medical
emergency relating to breathing problems.) In his incident report, the officer
said that other A Wing officers arrived at the cell within seconds.
22. A nurse held the Hotel 3 radio that day and was working on D Wing when the
first request came through. She initially moved towards a telephone to call A
Wing for further information. However, the code blue call came through
almost immediately afterwards and so she headed straight for A Wing where
she arrived within two minutes. Following her arrival, the first officer on scene
left the cell to give his healthcare colleagues more room to work, and returned
to his normal duties. The cellmate was removed from cell A3-11 and taken to
cell A3-08.
23. The Hotel 3 nurse felt for the man’s pulse which was faint, and then turned
him onto his back. His face looked blue in colour so the nurse inserted an
airway and asked a colleague to collect the oxygen cylinder. By the time the
airway was inserted, a second nurse had arrived with the oxygen and they
began cardio pulmonary resuscitation.
24. The Hotel 3 nurse told an officer that an ambulance would be needed and this
request was made by the control room at 12.32pm. Soon afterwards, more
nurses and the doctor arrived at the cell and assisted with the resuscitation
attempt. An ambu-bag (a manual ventilation bag) was placed on the man and
connected to the oxygen. A defibrillator was used but staff were not told to
Final Report: Date: March 2009 8
shock him as his heart was asystole, meaning that it did not have a shockable
rhythm. (A defibrillator is a machine that provides an electric shock to the
heart to try to get it started again. A defibrillator would not be used when the
heart does have not sufficient rhythm as it would not have any effect.)
25. The ambulance arrived at the prison at approximately 12.40pm, and was
directed through to A Wing. It arrived at A Wing at 12.41pm, and the
paramedics arrived at the cell within ten minutes of the ambulance being
called. The paramedics took over CPR and inserted an endotracheal tube
into the man’s throat to try to ensure that air reached his lungs. During the
resuscitation attempt the man breathed on his own for short periods of time.
However the electrocardiogram reading was asystole throughout.
26. The governing Governor was informed of events at 12.55pm and arrived at
the man’s cell at 1.08pm. At 1.18pm, the paramedics took the man to the
ambulance in a wheelchair. The ambulance left HMP Leeds at 1.27pm with
two officers accompanying him to the hospital. They arrived at Leeds General
Infirmary at 1.30pm but, following further attempts at resuscitation, he was
declared dead by the supervising doctor at 1.40pm.
27. While the man was taken to hospital, the duty governor undertook a hot
debrief at 1.30pm. It was attended by all the members of staff who were
involved in the situation, including healthcare staff. The debrief was felt to be
useful by those who attended as it allowed staff to express their emotions and
recount what they had undertaken. The IMB, chaplaincy and Care Team
were able to offer support. Following the man’s death the Governor released
a notice to inform staff and prisoners.
28. A senior officer (SO) was appointed Family Liaison Officer (FLO) at 2.00pm
following the news of the man’s death. The SO’s first task was to establish
contact with his family to inform them of his passing. The SO initially looked
on the computer system and in the man’s core record for the information. Her
searches revealed that there were three family members recorded – his 16
year old son, his sister and a woman who worked for the charity that the man
supported. There was no address given for his son or sister. The SO
contacted the appropriate Social Services Department who were able to
provide an address for his son’s mother. The prison was aware that his son
was only 16 years old and, as he was a minor, the SO needed to find out if an
adult would be present when he was told of his father’s death. The Social
Services Department confirmed that his mother was with him at home, as they
had just spoken to her. The SO, the duty Governor, and a member of the
chaplaincy team drove to the family’s address and broke the news of the
man’s death to them at 5.20pm.
29. The family were understandably shocked by the news, but did not wish any
further involvement and requested the prison organise the funeral and inform
them of the date. His property was returned to his family.
Final Report: Date: March 2009 9
30. The friend of the man who worked for the charity was made aware of his
death but the prison was unable to contact the man’s sister as neither
telephone number was in use.
After 16 September
31. The SO rang the mother of the man’s son on 22 September to inform the
family that the cause of death was a pulmonary embolism. She asked if the
man could be laid to rest at a named cemetery in their local area. Following
the family’s choice of cremation and the issuing of an interim death certificate
from the Coroner, the SO organised the funeral for 8 October and the prison
offered to pay the expenses. Prisoners on A Wing bought a wreath, and the
SO and two members of staff from the workshops attended. The family were
offered a visit to the prison but they declined the offer.
Final Report: Date: March 2009 10
ISSUES
The man’s clinical care while in prison
32. The man only had brief contact with the medical staff while at Leeds. Upon
his arrival his blood pressure was recorded as 116/76 which the clinical
reviewer describes as a reading which would have given no cause for
concern. After the initial appointments with the healthcare team regarding his
stress-related symptoms, he did not see a doctor from late 2006 until he
collapsed.
33. The clinical reviewer notes that the man only apparent risk factor in terms of
the development of coronary problems was his smoking. In his clinical review
the doctor recommends:
“The Head of Healthcare should consider that those prisoners identified
at high risk of cardiovascular disease are managed in line with agreed
national standards of care.
“The Head of Healthcare should consider that all smokers are offered
appropriate smoking cessation services which are at least equivalent to
those offered in the community. And that these are re-offered at least
annually even if initially declined.”
34. The clinical reviewer concludes his account of the man’s clinical care at Leeds
by writing:
“… I find that the clinical care of [the man] during his time in prison was to an
acceptable standard and equivalent to the care that could have taken place in
a community setting.”
The attempted resuscitation of the man
36. The first officer on scene responded to a cell bell at approximately 12.27pm
when he spoke to the cellmate. Once told about the man’s condition the
officer called for healthcare assistance. The initial request did not indicate an
emergency which explains why the Hotel 3 nurse was originally going to
telephone A Wing for more information. It was only after the officer went into
the cell and saw the severity of the man’s condition that a code blue call was
made. However, the difference between the two calls was a matter of
seconds and, prior to the officer seeing the man, he had insufficient
knowledge of the situation to immediately alert staff to an emergency.
37. The arrival of the wing staff was very prompt and the Hotel 3 nurse arrived
from D Wing within two minutes. Once at the cell, CPR was carried out
promptly and appropriately. The response time of the paramedics was also
impressive and they continued the CPR for 20 minutes before the decision
was made to take the man to hospital.
38. The clinical reviewer says that:
Final Report: Date: March 2009 11
“… the procedures for dealing with a medical emergency on A Wing appear to
have been followed correctly and there was an adequate response in terms of
appropriate numbers of the trained personnel arriving in a timely fashion to try
and resuscitate [the man]. The manner of resuscitation using chest
compressions and providing artificial respiration together with continuous
oxygen appears appropriate and of a sufficiently high standard. The use of
equipment in terms of a cardiac monitor and defibrillator was also a sign of
good clinical practice in a setting such as a prison. This sort of equipment is
not always readily available in community settings.”
39. The clinical reviewer does raise some concerns over the quality of the record
keeping which have resulted in a recommendation to the Head of Healthcare:
The Head of Healthcare should remind staff involved in serious medical
incidents such as resuscitations of the importance of making same day
entries in the medical records.
40. However, the clinical reviewer also writes:
“…the care provided at the time of his collapse was in my opinion to a
relatively high standard and was at least equivalent if not better than that
which could have been expected in the community. I have no cause for
concern that anything could have been done differently at the time of his
collapse or that there were significant delays during resuscitation which led to
any worsening of the eventual outcome.”
41. I endorse these views.
Liaison with the man’s family
42. The Family Liaison Officer had some difficulty in contacting the family due to
the incomplete details provided by the man. The prison was unable to contact
his sister but tried each of the numbers provided by him. Prison staff informed
his friend from the charity that he supported.
43. Contacting the man’s son required the SO to ask the Social Services
Department for the address of his mother. It was also necessary to ensure
that she would be present as his son was a minor. Prison staff spent quite a
long time establishing these details, so his son and his mother were only
informed of his death at 5.20pm on 16 September. However, given the
difficulties involved and the need to ensure that his mother was present at the
time of the meeting, I think that staff acted appropriately and as quickly as
they could. Having complete next of kin details would have helped prison
staff contact the man’s family quicker or, in the case of his sister, at all. I
therefore recommend:
The Governor should remind staff of the need to collect next-of-kin
details continuously throughout the sentence of a prisoner.
Final Report: Date: March 2009 12
44. The family wanted no further involvement and wished the prison to organise
the funeral. I understand that the SO organised the funeral at a location that
the family chose, and the prison offered to meet the expenses. I recognise
the efforts of the Family Liaison Officer in undertaking this task. The prison
also returned the man’s remaining money and valuables to the family, and are
currently organising the return of his remaining property. This seems entirely
in line with the prison’s responsibilities.
Support for staff and prisoners
45. The Governor released a notice to inform staff and prisoners of the death of
the man and alerted the IMB, Care Team and chaplaincy. All members of
staff involved in the resuscitation attempt to whom my investigator spoke were
complimentary about the support offered by the prison, and said there was
considerable support available if needed.
Final Report: Date: March 2009 13
RECOMMENDATIONS
I make four recommendations:
1. The Governor should remind staff of the need to collect next-of-kin details
continuously throughout the sentence of a prisoner.
The Prison Service accepted this recommendation and said:
“HMP Leeds now has forms on the PIDs (Prisoner Info Desks) so that
prisoners can submit any changes as and when they occur. Additionally
Personal Officers will collect this information as part of their work (under the
new personal officer scheme which is being implemented) and remind
prisoners of the need to keep them informed if there are any changes.”
2. The Head of Healthcare should consider that those prisoners identified at high
risk of cardiovascular disease are managed in line with agreed national
standards of care.
The Prison Service accepted this recommendation and said:
“This will be taken forward as an element of the chronic disease management
plan.”
3. The Head of Healthcare should consider that all smokers are offered
appropriate smoking cessation services which are at least equivalent to those
offered in the community. And that these are re-offered at least annually even
if initially declined.
The Prison Service accepted this recommendation and said:
“A joint initiative with Public Health Services will be undertaken.”
4 The Head of Healthcare should remind staff involved in serious medical
incidents such as resuscitations of the importance of making same day entries
in the medical records.
The Prison Service accepted this recommendation and said:
“Staff reminded though staff meetings. Annual medical records audit
implemented. Regular peer reviews of medical records to aid learning.”
Final Report: Date: March 2009 14